Rheumatoid Arthritis — SCE Rheumatology MCQ

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HardRheumatoid ArthritisRheumatoid ArthritisSCE Rheumatology

A 65-year-old man has active seropositive rheumatoid arthritis despite methotrexate. He developed secondary loss of response to both adalimumab and etanercept. He has previously been treated for recurrent diffuse large B-cell lymphoma, which has been in complete remission for 4 years. Following review with haematology, a further advanced therapy for his rheumatoid arthritis is indicated. Which therapy is most appropriate?

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Correct answer: E — Rituximab

Rituximab is the most appropriate advanced therapy. The 2024 EULAR points to consider state that B-cell-depleting therapy may be preferred when inflammatory arthritis requiring targeted treatment occurs in a patient with previous lymphoma. Rituximab is also an established NICE option for active rheumatoid arthritis after TNF-inhibitor failure. Tocilizumab is effective after TNF-inhibitor failure but has no corresponding lymphoma-specific preference. Infliximab would represent a third TNF inhibitor after secondary failure of two agents from that class. Upadacitinib and baricitinib are JAK inhibitors rather than biologics; MHRA advice is to avoid this class unless no suitable alternative exists in patients aged 65 years or older or with malignancy risk factors. Treatment should remain coordinated with haematology because the lymphoma-specific evidence is based primarily on expert consensus rather than comparative trials.

Reference: EULAR, 2024 EULAR points to consider on the initiation of targeted therapies in patients with inflammatory arthritis and a history of cancer, point to consider 7, 2024. https://ard.bmj.com/content/early/2024/12/20/ard-2024-225982